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Heckscher D, Jalfon M, Buck MB, Abello A, Nguyen JV, Casilla-Lennon M, Leapman MS, Hittelman AB, Teitelbaum J, Emerson BL, Kenney PA, Cavallo JA, Lambert S. Implementation of a health system intervention to reduce time from presentation to surgical intervention for pediatric testicular torsion. J Pediatr Urol 2024; 20:254.e1-254.e7. [PMID: 38030428 DOI: 10.1016/j.jpurol.2023.10.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/29/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE Testicular salvage rates for torsion are time-dependent1. Door to detorsion time has been identified as an independent testicular survival factor2. We describe an initiative to reduce door to incision (DTI) time for pediatric testicular torsion. MATERIALS AND METHODS An institutional multidisciplinary quality improvement initiative with a primary outcome of reducing DTI time for pediatric testicular torsion was developed with multidisciplinary stakeholders. Several process and balancing measures were used as secondary outcomes to help interpret and verify the observed change in DTI time. Interventions were implemented in cycles. Initial interventions standardized assessment of suspected torsion by Emergency Medicine utilizing a validated scoring system. A threshold Testicular Workup for Ischemia and Suspected Torsion (TWIST) score led to parallel notification of essential services for rapid assessment and case prioritization3. Subsequently, bedside ultrasound in the Emergency Department was implemented. Progress was tracked in a live dashboard and analyzed with X-mR process control charts and Nelson rules. These tools are used in quality improvement and process control to demonstrate the significance of changes as they are being implemented, prior to when traditional hypothesis testing would be able to do so. We aimed to increase the proportion of cases with DTI times under 4 h from 64% to >90% within one year. RESULTS We observed 22 torsion cases prior to and 62 following initial implementation. The percentage of cases with DTI times under 4 h improved from 64% to 95%. At week 29, a shift identified a significant change on the X chart, with reduction in mean DTI time from 221 to 147 min. At the same time, a shift on the mR chart identified reduction in patient-to-patient variation. Mean time from arrival to Urology evaluation decreased from 140 to 56 min, mean time from arrival to scrotal ultrasound decreased from 70 to 36 min, and mean time from scrotal ultrasound to surgical incision decreased from 128 to 80 min. These improvements highlight the two key successes of our project: application of the TWIST score and bedside ultrasound for rapid assessment of suspected testicular torsions, and parallel processing of the evaluation and management. CONCLUSIONS Implementation of a protocol for pediatric testicular torsion increased the proportion of cases with DTI time <4 h to 95%, decreased mean DTI time, and decreased variation. Our protocol provides a model to improve timeliness of care in treating pediatric testicular torsion.
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Affiliation(s)
| | | | | | | | | | | | - Michael S Leapman
- Yale University School of Medicine, New Haven, CT, USA; Veterans Affairs Connecticut Healthcare System, West Haven and Newington, CT, USA
| | | | | | | | | | - Jaime A Cavallo
- Yale University School of Medicine, New Haven, CT, USA; Veterans Affairs Connecticut Healthcare System, West Haven and Newington, CT, USA.
| | - Sarah Lambert
- Yale University School of Medicine, New Haven, CT, USA
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Lee WG, Ourshalimian S, Keane OA, O'Guinn M, Odegard MN, Sparks SS, Kelley-Quon LI. Sex-based Disparities in the Management of Pediatric Gonadal Torsion. J Pediatr Surg 2024:S0022-3468(24)00167-2. [PMID: 38599909 DOI: 10.1016/j.jpedsurg.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 03/01/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION In 2015, the U.S. News and World Report (USNWR) implemented a quality metric to expedite surgery for testicular torsion (TT), but not ovarian torsion (OT). This study examined OR timing among children with suspected TT and OT before and after this metric. METHODS A single-center retrospective cohort study of children (1-18yr) who underwent surgery for suspected gonadal torsion was performed. Time to OR (TTOR) from hospital presentation to surgery start was calculated. An interrupted time series analysis identified changes in TTOR for suspected TT versus OT after the 2015 USNWR quality metric. RESULTS Overall, 216 patients presented with TT and 120 with OT. Median TTOR for TT was 147 min (IQR:99-198) versus 462 min (IQR:308-606) for OT. Post-quality metric, children with TT experienced a 27.8 min decrease (95% CI:-51.7,-3.9, p = 0.05) in annual median TTOR. No significant decrease was observed for children with OT (p = 0.22). Children with history of a known ovarian mass (N = 62) experienced a shorter TTOR compared to those without (422 vs 499min; p = 0.04). CONCLUSION Implementation of a national quality metric for TT expedited surgical care for children with TT, but not children with OT. These findings highlight the need for equitable quality metrics for children presenting with suspected gonadal torsion. LEVEL OF EVIDENCE III. TYPE OF STUDY Retrospective Comparative Study, Observational Cohort Study.
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Affiliation(s)
- William G Lee
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA.
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Olivia A Keane
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Makayla O'Guinn
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Marjorie N Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Stephen S Sparks
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA; Department of Population and Public Health Sciences, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA
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Gopal M, Thattaruparambil V, McLaran P, Weisser S, Auth J. Emergency scrotal exploration in children: Following a change in mindset in the UK. J Pediatr Urol 2023:S1477-5131(23)00126-2. [PMID: 37080795 DOI: 10.1016/j.jpurol.2023.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/31/2023] [Indexed: 04/22/2023]
Abstract
A survey of 200 emergency scrotal explorations done over four paediatric surgical centres in the UK revealed that the incidence of finding testicular torsion (TT) was 24% and the preoperative utilisation of Doppler ultrasound (DUS) was 10% [1]. We changed our practice to include better preoperative utilisation of a clinical risk score (TWIST) and DUS. This led to a significant increase in the incidence of finding TT from 18% to 53%. Obtaining a DUS did not lead to an increase in our orchidectomy rate. Adopting this change is possible in an NHS setting and it has significant clinical and economic benefits.
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Affiliation(s)
- Milan Gopal
- Department of Paediatric Surgery and Urology, Great North Children's Hospital, Newcastle upon Tyne, UK.
| | - Vinayak Thattaruparambil
- Department of Paediatric Surgery and Urology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Pearly McLaran
- Department of Radiology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Swantje Weisser
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology, University Hospital Goettingen - Goettingen, Germany
| | - Janina Auth
- Friedrich-Alexander University Erlangen-Nurnberg, Germany
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Cabo J, Graham K, Chen H, Zhao S, Burger C, Arnold D, Taylor A, Pope J, Clayton D, Brock JW, Adams M, Adams C, Thomas J. Increasing utilization of the TWIST score in workup of patients with acute scrotal pain: Role in diagnosis and risk stratification. J Pediatr Urol 2022; 18:845.e1-845.e8. [PMID: 36244901 DOI: 10.1016/j.jpurol.2022.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 08/25/2022] [Accepted: 09/20/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The TWIST score is a 5-component physical examination score used to aid in diagnosis of testicular torsion (TT) and could lessen need for radiologic testing in certain clinical scenarios. OBJECTIVE TWIST use was not previously widespread at our institution. The primary objective of this quality improvement study was to achieve 100% compliance in TWIST utilization among urology and ED residents and to assess for score concordance between ED and urology assessments. Secondary goals were correlation of TWIST components with need for orchiectomy. METHODS ED staff were educated about the TWIST score and asked to complete assessment for patients presenting with acute scrotal pain. Simultaneously, an electronic medical record-based dot phrase was introduced for urology trainees to complete an independent TWIST evaluation. Spearman correlation was performed to assess association between ED and Urology TWIST scores. Multivariable logistic regression was performed to assess association of TWIST score components and need for orchiectomy. RESULTS 103 patients presented to the ED from 3/2018-11/2020 with a complaint of acute scrotal pain; 47 were diagnosed with torsion. As compared to our retrospective cohort, the documentation rate of complete TWIST score components on exam rose from 9% to 98% (P < 0.001) on ED evaluation and 16%-66% on urology evaluation (P < 0.001). Rates of repeat ultrasound for patient's transferred between facilities was similar (58% vs. 63%; p = 0.66) as was median time to OR (160 min vs. 145 min; p = 0.5). Using TWIST cutoff of >5 yielded a specificity of 94.5% for diagnosis of torsion, with corresponding strong correlation between ED and urology scores (rho = 0.71). A firm testicle was noted on urology evaluation in 100% of orchiectomy patients (vs. 61% of salvage patients) with persistent association after controlling for duration of symptoms (OR 28.1; P = 0.016). DISCUSSION Through two-pronged quality improvement efforts, we significantly improved utilization of the TWIST score by ED and urology staff for workup of patients with acute testicular pain. We confirmed the high sensitivity and specificity of the TWIST score and demonstrated inter-rater reliability between ED and urology assessments. On prospective analysis, testicular firmness on exam was predictive of need for orchiectomy. CONCLUSION The TWIST score is an accurate diagnostic tool for both ED and urology providers in workup of children with acute scrotal pain, with a normal score essentially ruling out the condition. Future work should aim at minimizing unnecessary testing in patients demonstrated to be at high risk for torsion.
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Affiliation(s)
- Jackson Cabo
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA.
| | - Kyle Graham
- Surgical Outcomes Center for Kids-Monroe Carrell Jr Children's Hospital, Department of Biostatistics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232, USA
| | - Heidi Chen
- Surgical Outcomes Center for Kids-Monroe Carrell Jr Children's Hospital, Department of Biostatistics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232, USA
| | - Shilin Zhao
- Surgical Outcomes Center for Kids-Monroe Carrell Jr Children's Hospital, Department of Biostatistics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232, USA
| | - Catherine Burger
- Department of Emergency Medicine, Vanderbilt University Medical, Center1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Donald Arnold
- Department of Emergency Medicine, Vanderbilt University Medical, Center1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Abby Taylor
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
| | - John Pope
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
| | - Douglass Clayton
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
| | - John W Brock
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
| | - Mark Adams
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
| | - Cyrus Adams
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
| | - John Thomas
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
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Schlomer BJ. Commentary to: Validation of testicular workup for ischemia and suspected torsion score in patients with acute scrotum. J Pediatr Urol 2022; 18:691-692. [PMID: 36055878 DOI: 10.1016/j.jpurol.2022.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Bruce J Schlomer
- University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Castle C, Beasley SW, Taghavi K. Access to emergency paediatric surgery for testicular torsion or intestinal volvulus in New Zealand: A system perspective. J Paediatr Child Health 2022; 58:146-151. [PMID: 34375478 DOI: 10.1111/jpc.15684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 11/30/2022]
Abstract
AIM The risk of organ loss is increased in children with testicular torsion or intestinal volvulus if surgical management is not expedient. The current retrospective study aims to review the time-course from first symptom to 'knife to skin' in these conditions, to determine where delays occur and facilitate a systems approach to better manage these children. METHODS One hundred consecutive paediatric cases of scrotal exploration for presumed testicular torsion, and 100 neonatal cases presenting with possible malrotation/volvulus were analysed to evaluate the exact time-course of events from admission to surgery. RESULTS (i) Scrotal exploration: the median time from onset of symptoms to presentation was 12 h (interquartile range (IQR): 5-48 h). In children over 5 years of age, 36% (33/93) were transferred from an external district service area. (ii) Malrotation/volvulus: the median duration of symptoms prior to arrival/assessment was 12 h (IQR: 4-24 h). The median cumulative in-hospital time was over 6 h (368 min, IQR: 247-634 min). CONCLUSIONS Time to presentation contributes significantly to testicular ischaemic time. This delay to timely surgical intervention is multi-factorial, and must be addressed at a public health level. Support and training in the management of testicular torsion should be provided to all adult surgeons/trainees that may care for these children. In general, this condition is best managed at the presenting hospital whenever appropriate expertise is available. Novel pathways that streamline care may improve efficiency at an institutional level. Addressing issues of access to specialised neonatal surgery is more vexed on account of the tyranny of distance, and the pre-requisite level of surgical expertise required.
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Affiliation(s)
- Cameron Castle
- Department of Paediatric Surgery, Child Health Service, Wellington Regional Hospital, Wellington, New Zealand
| | - Spencer W Beasley
- Department of Paediatric Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Kiarash Taghavi
- Department of Paediatric Surgery, Child Health Service, Wellington Regional Hospital, Wellington, New Zealand.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
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Shields LBE, Daniels MW, Peppas DS, Rosenberg E. Testicular Torsion in Patients With Intellectual and Developmental Disabilities. Glob Pediatr Health 2021; 8:2333794X211059119. [PMID: 34869797 PMCID: PMC8637397 DOI: 10.1177/2333794x211059119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/23/2021] [Indexed: 11/17/2022] Open
Abstract
Patients with intellectual/developmental disabilities are at risk of delayed diagnosis of testicular torsion due to their inability to effectively communicate their symptoms. We identified males ages 1 to 18 years with testicular torsion between January 1, 2015 and December 31, 2020, focusing on patients with intellectual and/or developmental disabilities. Of the 140 patients with testicular torsion, 5 (3.6%) patients exhibited intellectual/developmental disabilities with an inability to effectively verbalize testicular/groin/scrotal pain. The patients with intellectual/developmental disabilities underwent more orchiectomies (5/5, 100%, P = .009) and had a longer duration of symptoms (median = 48 hours, P = .047) compared to those without intellectual/developmental disabilities (51/135, 38% and median = 9 hours, respectively) (51/134, 38%) (P = .038). Parents and other caregivers of males with intellectual/developmental disabilities who are unable to adequately verbalize their testicular/groin/scrotal pain should be cognizant of the signs and symptoms associated with testicular torsion, perform a genitalia examination, and seek an immediate evaluation to diagnose and treat this urgent condition.
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Li XL, Lu SY, Liu TT, Zhang QM, Zhang WP, Jia LQ. The theoretical method and clinical application of testicular torsion. Int Urol Nephrol 2020; 52:1009-1014. [PMID: 32052246 DOI: 10.1007/s11255-020-02382-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/13/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION This study aims to explore the theoretical method and clinical application of manipulation reduction for testicular torsion. METHODS A total of 28 patients with testicular torsion were recruited from the Emergency Surgery Department of Beijing Children's Hospital affiliated to Capital Medical University from July 2016 to July 2018. Among these patients, 22 patients (age: 10.80 ± 3.50 years old) were treated with manual reduction using the elastic retraction method and push-and-turn method. Observation indexes included dramatically alleviated or completely disappeared pain without general anesthesia; the spermatic cord being smooth and unknotted; the restoration of the suffered testis to normal anatomical position under ultrasonography monitoring; blood flow signals increased in the affected testis and epididymis, which was regarded as the main sign of a successful reduction. RESULTS Among the 22 cases who received manual reduction, 19 patients were successfully treated (left side: n = 11, right side: n = 8) with a total success rate of 86.36%. The other three cases showed either incomplete (n = 2) or failed (n = 1) reposition. Among the 19 patients who were successfully treated by manual reduction, 2 of them did not undergo prophylactic orchiopexy, and no abnormalities were found during the follow-up. CONCLUSION The reduction of testicular torsion using the elastic retraction method and push-and-turn method may improve the success rate of the manual reduction of testicular torsion, especially for incomplete testicular torsion. Furthermore, manual reduction may help increase the rate of testicular salvage in a timely manner before emergency surgery. Hence, this skill should be extended to primary hospitals to reduce the possibility of testectomy caused by testicular torsion.
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Affiliation(s)
- Xian-Ling Li
- Department of Emergency Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 of Nanlishi road, Xicheng District, Beijing, 100045, China
| | - Shou-Yan Lu
- Department of Pediatric Surgery, Beijing Aiyuhua Women and Children Hospital, Beijing, 100176, China
| | - Ting-Ting Liu
- Department of Emergency Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 of Nanlishi road, Xicheng District, Beijing, 100045, China
| | - Qin-Ming Zhang
- Department of Pediatric Surgery, United Family Hospital, Beijing, 100016, China
| | - Wei-Ping Zhang
- Department of Urology Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 of Nanlishi road, Xicheng District, Beijing, 100045, China.
| | - Li-Qun Jia
- Department of Ultrasound Imaging, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 of Nanlishi road, Xicheng District, Beijing, 100045, China
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O'Kelly F, Hannick JH, Wolfstadt JI, Ward SE, Koyle MA. Quality improvement in pediatric urology-a historical perspective on street pumps, puerperal fever, surgical infection, and contemporary methodology. J Pediatr Urol 2019; 15:495-502. [PMID: 31630935 DOI: 10.1016/j.jpurol.2019.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 08/26/2019] [Indexed: 11/20/2022]
Abstract
Quality improvement and patient safety (QIPS) can trace its origin back to the court of Hammurabi (circa 1700BC). However, it did not begin its evolution into its present methodology until the mid-19th century. It was through the application of quantitative parameters around the time of World War I that the field of QIPS has matured and gained a significant presence in the practice of medicine. Herein, the authors present a historical overview of this increasingly important field and correlate the current pediatric urology literature that has arisen from it. Because QIPS research is likely to contribute to efficient, streamlined health care through rapid changes to routine clinical practices, it would behoove pediatric urologists to familiarize themselves with its history and fundamental concepts.
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Zee RS, Bayne CE, Gomella PT, Pohl HG, Rushton HG, Davis TD. Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion. J Pediatr Urol 2019; 15:473-479. [PMID: 31444122 DOI: 10.1016/j.jpurol.2019.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 07/11/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Timely diagnosis and management of testicular torsion is of paramount importance. Furthermore, time to surgical intervention is a benchmark for the quality of care provided by pediatric urologists included in US News and World Report (USNWR) methodology. OBJECTIVE We sought to optimize management of acute testicular torsion at a single institution by decreasing time from presentation to definitive management through the creation and implementation of a clinical care pathway (accelerated care of torsion or ACT) for acute testicular torsion in a 2-year period. STUDY DESIGN Multidisciplinary process mapping involving the emergency department (ED), radiology, anesthesiology, peri-operative services, and operating room (OR) teams resulted in development of the ACT pathway with the goal of achieving surgical intervention within 4 h of arrival at our institution. The accelerated care of torsion pathway was implemented in April 2016. Thirty-eight consecutive acute torsion cases were then prospectively evaluated from April 2016 to April 2018. For process measures, we recorded triage to OR times and mode of presentation. For outcome measures, we examined orchiectomy rates. We retrospectively reviewed 97 cases of acute torsion from 2004 to 2016 as a control. RESULTS Time from ED triage to OR start decreased from a median 196 min (interquartile range [IQR] 137-249 min) to 127 min (IQR 100-148 min; P < 0.0001) for all cases of acute torsion. In the control group, 72% of cases met the USNWR criteria for acute treatment of torsion. After ACT implementation, 100% of cases reached the OR within the 240 min time frame. Orchiectomy rates were performed in 24% of control cases vs 30% after ACT implementation (P = NS). Survival curve analysis demonstrated no significant difference in probability of testis salvage before or after implementation of the ACT pathway. DISCUSSION In agreement with similar studies, despite a significant reduction in triage to OR times, the orchiectomy rate approached 30%. This outcome did not significantly improve after implementation of the ACT pathway. Overall ischemia time was a more important determinant of testis salvage. Study limitations include limited patient follow-up to assess testis atrophy. CONCLUSIONS The multidisciplinary creation and implementation of a clinical pathway for the care of acute testis torsion has significantly decreased the time from ED to OR in our institution. However, overall orchiectomy rate was not significantly affected.
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Affiliation(s)
- R S Zee
- Children's National Medical Center Division of Urology, Washington, D.C, USA.
| | - C E Bayne
- University of Florida Division of Pediatric Urology, Gainesville, FL, USA
| | - P T Gomella
- George Washington University Department of Urology, Washington, D.C, USA
| | - H G Pohl
- Children's National Medical Center Division of Urology, Washington, D.C, USA
| | - H G Rushton
- Children's National Medical Center Division of Urology, Washington, D.C, USA
| | - T D Davis
- Children's National Medical Center Division of Urology, Washington, D.C, USA
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Polites SF, Lautz TB, Jenkins TM, Dasgupta R. Implications of transfer status on bowel loss in children undergoing emergency surgery for malrotation. J Pediatr Surg 2019; 54:1848-1853. [PMID: 31003730 DOI: 10.1016/j.jpedsurg.2019.01.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/13/2018] [Accepted: 01/09/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Malrotation with midgut volvulus is a time-sensitive pediatric surgical disease that requires emergent operative exploration to avoid bowel loss; however, it also requires specialized pediatric care. The purpose of this study was to identify disparities in bowel resection in children who underwent emergency surgery for malrotation; particularly the role of transfer status. METHODS The Pediatric Health Information System was used to identify a multicenter cohort of patients who underwent emergency surgical intervention for malrotation. Univariate and multivariable analyses were used to determine factors associated with the primary outcome of bowel resection; secondary outcomes included surgical complications, prolonged length of stay, TPN dependence, and death. RESULTS Of 3373 patients with malrotation included, 44.8% were transferred in. Younger age, prematurity and other comorbidity, nonwhite race, and public insurance were associated with transfer. Transferred patients were more likely to undergo bowel resection on univariate (30.7 vs 16.4%, p < .001) and multivariable analysis (RR =1.38, p < .010). After adjusting for bowel resection, only patient factors including age and comorbidity were associated with surgical complications, TPN dependence, and death. CONCLUSION Patients who require hospital-to-hospital transfer for emergent surgical management of malrotation are more likely to require bowel resection which is in turn associated with greater morbidity. Further work is needed to optimize access to prompt surgical care for this condition especially given race and insurance disparities in transfer status. LEVEL OF EVIDENCE III, prognostic study.
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Affiliation(s)
- Stephanie F Polites
- Division of General and Thoracic Pediatric Surgery, Cincinnati, Children's Hospital Medical Center.
| | - Timothy B Lautz
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University
| | - Todd M Jenkins
- Division of General and Thoracic Pediatric Surgery, Cincinnati, Children's Hospital Medical Center
| | - Roshni Dasgupta
- Division of General and Thoracic Pediatric Surgery, Cincinnati, Children's Hospital Medical Center
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Abstract
OBJECTIVES Testicular torsion/detorsion (T/D) is a well-known cause for infertility. Pioglitazone is an agonist of peroxisome proliferator activated receptor-gamma (PPAR-γ). Previous studies have shown that pioglitazone has anti-inflammatory, antioxidant and antiapoptotic properties. The present study hypothesized that pioglitazone may be protective against the testicular T/D tissue insults, and the possible pathophysiological mechanisms involved in this effect were also investigated. MATERIALS AND METHODS Rats were randomly divided into four groups: sham group, T/D group where testicular torsion was performed for 4 hr followed by 4 hr of detorsion and two pioglitazone-treated groups (1 mg/kg and 3 mg/kg, by single intraperitoneal injection 30 min prior to detorsion). At the end of reperfusion period, blood, ipsilateral and contralateral testicular tissue samples were obtained for biochemical and histopathological examination. RESULTS Pioglitazone reduced oxidative tissue damages, inflammatory mediators, and apoptotic markers and enhanced the total antioxidant status, and AMP-activated protein kinase level. Moreover, pioglitazone improved spermatogenesis evidenced by increased Johnsen's score and reversed the histopathological damages induced by testicular T/D. The effects of pioglitazone were higher with the dose of 3 mg/kg. CONCLUSION Pioglitazone exhibited a protective effect against the deleterious actions of testicular T/D. This beneficial potential of pioglitazone may be attributed to its antioxidant, anti-inflammatory and antiapoptotic properties, which was more obvious with the dose of 3 mg/kg. Pioglitazone may be a promising therapy for testicular T/D.
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Affiliation(s)
- Nevertyty Mohamed Mahmoud
- Department of Pharmacology, Faculty of Medicine, Zagazig University, Egypt,Corresponding author: Nevertyty Mohamed Mahmoud. Department of Pharmacology, Faculty of Medicine, Zagazig University, Egypt. Tel: 00201061329496;
| | - Soad Lotfy Kabil
- Department of Pharmacology, Faculty of Medicine, Zagazig University, Egypt
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Romao RLP, Anderson KH, MacLellan D, Anderson P. Point-of-care influences orchiectomy rates in pediatric patients with testicular torsion. J Pediatr Urol 2019; 15:367.e1-367.e7. [PMID: 31130503 DOI: 10.1016/j.jpurol.2019.04.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/13/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The objective of this study was to determine whether point-of-care (community hospitals vs. tertiary centers) or treatment-delaying variables (transfer, emergency room [ER] throughput, and distance traveled) affect orchiectomy rates in minors with testicular torsion (TT) using a national database. STUDY DESIGN This was a retrospective cohort study using prospectively collected data by the Canadian Institute of Health Information (CIHI) between 2010 and 2015. All Canadian male patients in the CIHI database aged <18 years with TT based on International Classification of Diseases (ICD) codes were included, except for those residing in Quebec. Variables collected were age, type of treating institution (community small/medium, community large, or tertiary/academic), transfer for definitive treatment, road distance traveled, and ER throughput. The outcome was testicular loss based on intervention codes for orchiectomy/orchidopexy. Univariable and multivariable analyses were performed using logistic regression. RESULTS A total of 1713 minors with TT were included. Overall orchiectomy rate was 28%. Most patients (52%) were treated at tertiary hospitals. Small/medium community hospitals depicted the lowest odds of orchiectomy on univariable and multivariable analyses (odds ratio [OR] = 0.54, confidence interval [CI]: 0.37-0.79, p < 0.001); academic hospitals were also associated with a lower odds of orchiectomy than large community ones. Transfer and distance traveled were not associated with the outcome. Age >12 and ER throughput less than 1 h were significantly associated with lower orchiectomy rates. In a subgroup analysis of patients aged <12 years (n = 278), transfer was the only factor associated with increased risk of orchiectomy (OR = 2.41 , CI: 1.09-5.33; p = 0.03). DISCUSSION This study showed that small and medium community hospitals had the lowest orchiectomy rates in minors with TT in Canada (Figure). However, on multivariable analysis, they performed similarly to tertiary/academic hospitals, with both being superior to large community hospitals. Transfer and distance traveled did not affect orchiectomy rates. Emergency room throughput had a statistically significant association with orchiectomy rates in every analysis and based on the study data would constitute the best target for policies aimed at reducing orchiectomy rates for TT in minors. The main limitation of this study is the inability to evaluate long-term testicular viability of patients not undergoing orchiectomy (i.e., true testicular salvage). CONCLUSIONS Type of hospital treating facility (point-of-care) affects orchiectomy rates in minors with TT. Small/medium community hospitals depict the lowest orchiectomy rates in Canada. Transfer to another facility for definitive care and distance traveled did not affect orchiectomy rates, except in a subgroup analysis of prepubertal boys. Longer ER throughput and prepubertal age were consistently associated with loss of the testicle.
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Affiliation(s)
- Rodrigo L P Romao
- Division of Pediatric Urology, IWK Health Centre; Department of Urology, Dalhousie University, Halifax, NS, Canada.
| | - Katherine H Anderson
- Division of Pediatric Urology, IWK Health Centre; Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Dawn MacLellan
- Division of Pediatric Urology, IWK Health Centre; Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Peter Anderson
- Division of Pediatric Urology, IWK Health Centre; Department of Urology, Dalhousie University, Halifax, NS, Canada
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Overholt T, Jessop M, Barnard J, Al-Omar O. Pediatric testicular torsion: does patient transfer affect time to intervention or surgical outcomes at a rural tertiary care center? BMC Urol 2019; 19:39. [PMID: 31101044 DOI: 10.1186/s12894-019-0473-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 05/06/2019] [Indexed: 12/16/2022] Open
Abstract
Background Testicular torsion (TT) is a urologic emergency that requires prompt surgical intervention. In rural Appalachia, patients are often transferred from surrounding communities due to lack of urologic care. We hypothesized that those transferred would have delayed intervention and higher rates of orchiectomy when compared to those who presented directly to our hospital. Methods We performed a retrospective review of patient charts with an ICD-9 diagnosis of TT from 2008 to 2016. Patients met inclusion criteria if diagnosis was confirmed by operative exploration. We compared rate of testicular loss and time until surgical intervention between groups. Results Twenty-three patients met inclusion criteria (12 transferred, 11 direct). Patient demographics did not significantly differ between groups. Transferred patients had a higher orchiectomy rate (33% v 22%,p = 0.41) although this was not statistically significant. Time to surgery from symptom onset was significantly longer in those transferred (12.9 h) compared to those not transferred (6.9 h, p = 0.02). Distance of transfer was not correlated with time of delay (r2 = 0.063). Conclusions Transferred patients with TT have numerically higher rates of orchiectomy which may reach significance in an appropriately powered study, and relative delays in surgical intervention. This study highlights the need for improved access to urologic care in rural areas.
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Chan EP, Wang PZT, Myslik F, Chen H, Dave S. Identifying systems delays in assessment, diagnosis, and operative management for testicular torsion in a single-payer health-care system. J Pediatr Urol 2019; 15:251.e1-251.e7. [PMID: 31005635 DOI: 10.1016/j.jpurol.2019.03.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/21/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Testicular torsion (TT) is a common pediatric urologic emergency. Management of TT is time sensitive and often confirmed on scrotal Doppler ultrasound (DUS). Acquiring DUS, however, can result in delays in the management of TT, affecting testicular salvage rates. OBJECTIVE The objective of this study is to identify delays in the assessment and diagnosis for patients presenting with TT to a Canadian academic hospital using patient flow analysis. STUDY DESIGN A retrospective review was performed for patients presenting to the emergency department (ED) who received a scrotal DUS to rule out possible TT between 2012 and 2017. The primary outcome measured cycle-time measurements (median time) between points along the clinical flow pathway for a patient with suspected TT. The secondary outcome assessed diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of standard scrotal DUS components (Doppler flow, arterial waveform, heterogeneous echotexture). RESULTS A total of 609 patients presented with an acute scrotum warranting a scrotal DUS to rule out TT; of which, 46 underwent scrotal exploration. Testicular salvage rate was 82.6% in the series (38 testes salvaged, 8 required orchiectomy). Median time from symptom onset to ED presentation for patients with possible TT was 4 h. After triage, a median of 79.8 min was required for ED physician assessment and an additional 48 min for scrotal DUS to be performed. Absence of Doppler flow on scrotal DUS had a 97.4% PPV for diagnosing TT confirmed during scrotal exploration. DISCUSSION Almost 4 h of in-ED time is required from triage to surgical intervention for potential TT at the institution. One area of delay is the time needed to conduct a scrotal DUS (48-128 min; Fig. 1). This represents an area of opportunity for patient flow optimization through the use of standardized clinical pathways and diagnostic adjuncts, such as point-of-care ultrasound. This study is limited in its retrospective nature and does not include patients with overt signs of TT who underwent surgical detorsion without need for scrotal DUS. CONCLUSION Patient flow delays to surgical intervention for patients with TT represent a preventable cause of orchiectomy in young men. This study identifies intervention points in patient-care flow pathways where delays to surgical intervention can be potentially reduced by up to 2 h. The findings support the need for further studies into the optimization of patient flow and management protocols to reduce delays in the diagnosis and management of TT.
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Affiliation(s)
- E P Chan
- Department of Surgery, Division of Urology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - P Z T Wang
- Department of Surgery, Division of Urology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Surgery, Division of Paediatric Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - F Myslik
- Department of Medicine, Division of Emergency Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - H Chen
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - S Dave
- Department of Surgery, Division of Urology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Surgery, Division of Paediatric Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
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